2017 Nohc Seminars and Workshops Form

For Office Use Only 2017 NOHC SEMINARS AND WORKSHOPS FORM April 24-26, 2017, Albuquerque, NM Proposal No: Please note: No funds will be available to support speaker travel. Orig. Date: Rev. Date: ***Red fields denotes required information Overall Session Title: Session Type Proposed ( ) Seminar ( ) Workshop Planning Committee has the final decision on program format Session Time Proposed ( ) 60 minutes ( ) 90 minutes Planning Committee has the final decision on program length Participant limit ** ( ) **If Workshop format selected above, please indicate how many participants can be accommodated Will this session have a sponsor? ( ) Yes ( ) No. If “yes” please indicate name of sponsor and contact information: Sponsorship

Session Coordinator/Moderator Name: Credentials: Title: Organization: Responsible for program development, Address: solicitation of speakers, their contact City, State, Zip: information. Email: Phone: Cell: On-Site Session Coordinator/ Name: Credentials: Title: Moderator Organization: Address: Carries out the responsibilities on-site if City, State, Zip: Session Coordinator/Moderator cannot attend conference. Email: Phone: Cell: Brief narrative of proposed purpose, goals and content of the session: 150 words maximum

Educational Objectives: 3 minimum

Speaker’s Name Topic/Title Speaker Credentials: Contact Information contacted Must be included for consideration (This information must be complete Must be included for consideration If no Y=Yes and for National Office to send agreement if session is selected credentials, please N=No and to follow up with speakers when necessary) indicate None 1. Title: Organization: Address: City, State, Zip: Email: Ph: Cell: 2. Title: Organization: Address: City, State, Zip: Email: Ph: Cell: 3. Title: Organization: Address: City, State, Zip: Email: Ph: Cell: *NOTE: Please refer to the Call for Seminar and Workshop Abstracts regarding the number of speakers and moderators for each proposed session format. Use additional pages as needed. Please e-mail completed form in Word format (NO pdfs) to Sandi Steil no later than October 2, 2016, to [email protected]. More information may be required for selected sessions.